It's probably legal, I figure. That is, the doctor is going to be in network with a limited number of plans that they have made particular agreements with. If they have deliberately chosen not to be in network for any individual plan that's sold through the exchanges, that seems like something that they could plausibly have done.

I could see it being a pure asshole move, or I could see it being connected to the problems with the website rollout. Wasn't there a recent story about a guy who enrolled through the website (re-starting five times in the early days), got confirmation from the website that he was confirmed, and then the website never forwarded his enrollment to the insurance company? And then he had a heart attack and the insurance company is all, never heard of him. And he is all, I have my printout confirming my enrollment right here.

So I am prepared to believe in website glitches. Or in asshole behavior.

Jesus, really? I never thought about it before, but now it seems like a glaring hole. What's the fucking point of having health insurance if you can still get screwed like this? Do insurance companies negotiate for doctors to accept only some of their plans? Can insurers sell plans that have no providers in network?

Anyway, legally compelled or not, I would think a big outfit like Blue Cross Blue Shield or Aetna would want to twist some arms: you accept all of our clients, or you don't get any of them. What's the downside for them?

3: I'm not sure you can meaningfully distinguish between "heard some story about a guy with a printout who turned out not to be insured so I must not treat patients with Obamacare" and "asshole behavior". It's not like insurance companies never denied claims pre-ACA.

4: So don't join the networks for those particular plans. There's no way the sign isn't a major asshole move.

Yes, it does seem like they're making a false dichotomy of exchange-based plans versus employer plans - this leaves individual off-exchange purchasers out in the cold.

If they're trying to avoid plans subject to ACA regulations, they would need to use only ERISA (large-employer self-insurance), which are mostly exempted, not the same as "employer".

It is probably legal as LB says, but I wonder if insurers would actually agree to contract with anyone subject to this kind of limitation. It is technically possible, I think, to distinguish plans sold on the exchange from other plans from the same insurer: they'll have different longer names on the insurance card (or they do in my state).

If I had a choice I would avoid this place - they seem liable to blame everything from deductibles to drug side effects on Obamacare. But of course insurance might limit your choices.

Hopefully right-wing people outraged by the limitations of Obamacare and right-wing lobbies outraged by the intrusions into private business can coalesce around some sort of public option for health insurance.

The answer to this one has to be "no" -- that'd be fraud, don't you think?

There's some missing regulatory structure around networks -- there needs to be some regulation placing the onus on the health care provider to affirmatively and correctly inform the patient whether or not they're in that patient's insurance's network, and if they provide services without having done so, prohibiting them from charging the patient more than the patient would have paid if they were in-network. Or something like that.

California has very strict regulations on plan network adequacy, appointment availability, etc., instituted following a messy leap into managed care in the late 90's. I presume there's something similar but much less toothy at the national level.

I thought the (well, one) problem that the ACA was supposed to address was that health insurance on the individual market was astronomically expensive and uniformly shitty. I was under the impression that the ACA was in large part a deal struck with the insurance agencies: if you guys agree to insure individuals and guarantee some minimum coverage in all your plans, then we'll require everyone to buy health insurance. I don't understand how this is even supposed to work if the plans available on the individual market still don't really have the negotiating power of the big insurance companies behind them.

Let's keep in mind, also, that the medical profession is also a racket in terms of the amount of money it sucks up - there's nothing making the current rates the right ones. Rates could be dropping because the ACA is finally making insurers try to compete on price, rather than by cherry-picking.

But in the end I doubt that "getting the incentives right" (i.e. trusting that headbutting of huge powerful entities will serve the public interest) is really going to help; there'll probably be some accommodation process between the bigs.

10 -- Before I picked from among the plans on the federal exchange, I got a look at the networks.

And even before that, I got a letter from Blue Cross cancelling my non-ACA compliant plan and offering to automatically roll me over into a compliant plan. With which, what does this provider think he's doing?

National physician groups are concerned the rates are so low that their members won't sign on to participate in ACA marketplace plans, and there will be no doctors to treat those newly covered patients.

The answer to this one has to be "no" -- that'd be fraud, don't you think?

It strikes me as fraudulent for an insurance company to have different prices for different plans agreed upon with a health care provider. Using power in numbers to negotiate price with the provider is the insurer's whole purpose. The difference between the different plans should only be in the transaction between the patient and the insurer, not in the transaction between the provider and the insurer.

19: So they can offer plans at different price points, I'd presume. There's more price pressure on the individual market now than on the employer market, for example. And it makes everything wonderfully confusing, to their benefit.

I believe doctors also have a right not to accept medicare or medicaid patients. I believe doctors actually have a right not to accept insurance, period, and to just require everyone to pay out of pocket. (I think basically no medical doctors do this, but a significant number of psychologists, physical therapists, etc. do, just because there are enough people willing to pay out of pocket and they don't want to deal with the insurance paperwork, the low reimbursement rates, etc.) So, given that, I wouldn't see any reason a doctor couldn't decide not to accept ACA plans.

Well, I'm certainly confused. If insurers negotiate on behalf of their individual-market clients separately, shouldn't that give them less bargaining power? I would expect this scenario to result in more $$$ for the doctor for individual-market plans, and hellishly expensive plans on the individual market.

I don't think so. The insurer just has to get enough doctors to take the plan to make an adequate network, whatever the legal standard for adequate is. So they set the price at whatever it takes to get the minimum necessary number of doctors to sign on.

23: Yeah, there's a super-fancy orthopedic surgeon in the area (has lots of nationally- and internationally-known athletes as patients) who isn't in any insurance networks. His attitude seems to be "you want the best, better be prepared to spend for it".

15: Before I picked from among the plans on the federal exchange, I got a look at the networks.

This was the big concern for my one son who finally got around to signing up late last night. It took him several days to get through on the phone and was in music mode for 90 minutes (I had little sympathy because he should have done it months ago to save $$s earlier). He had to do by phone because could not verify identity online due to no good credit history which is part of the bigger problem in his life. From the insurer website it does seem OK (and he did get a relatively high-end plan, but still cheaper than his current COBRA which would have expired in August). A lot of the issue around here is the massive UPMC-Highmark war which most people now think ascribe to the ACA because assholes and/or wildly misinformed. There were a number of Highmark plans already not accepted by any UPMC doctors/facilities which puts a huge crimp in choice around here a(and looks to get worse). The Highmark plans were all cheaper for same monetary coverage.

Anyway, as I (and many others have said), most of the ills of the prior US medical system will become the ills of ACA.

Not quite so assholish, but still annoying: when I went for a physical recently, I had to sign a page saying I would pay for any care that my insurer deemed not to fall into the category of "qualifying preventive care." The receptionist explained to me that since coverage for certain preventive care is now required, insurers are tightening their definitions as much as they can.

When I had a weird tumor-not-a-tumor removed from my eye socket, my dermatologist was really adamant that it be done by a plastic surgeon (because eyes? I dunno). Anyway, he kept referring me to all these Park Avenue eye surgery specialists who didn't take insurance (the first one he told me "Did my mother's eyes"). It turns out that -- SURPRISE! -- lots of fancy plastic surgeons don't take insurance (except for breast specialists), but there was one ophthalmologist/eye surgeon/plastic surgeon in NYC who did. And then I lost like $70 and still have a scar anyway.

That's not a claim that everyone or even many people would be well served without insurance, just that the overhead of dealing with insurance really is a material expense, plus since there are so few cash customers, many medical practices just set the initial price super high for reasons totally unrelated to what it might be profit-maximizing to charge cash customers in a true market.

I can absolutely vouch for 40.last. The M/dw/fe Center's fee schedule is 100% determined by the maximum reimbursement they can get from an insurer. I've asked whether that screws people who pay cash, and the answer is that those people are so rare that they're dealt with on a case by case basis (a chunk of them are poor, of course, and they get handled differently - I think we help find them medical assistance that is basically LIHEAP but for people who need medical care).

We're pro-ACA, of course, but it has resulted in new insurance plans that make our life as an independent provider more difficult.

40.last, 41: This is at the center of my dispute with my dentist. For instance, for a routine checkup/cleaning they went from two codes which they billed at x and y which then got paid at much lower w and z. They now do four codes all billed at what the insurance would ostensibly pay (so total initial "charge" is about the same), but in the event my insurance will not touch two of them, one is too lame, "Dental Education" or some such, and the other they say they will only pay to oral surgeons. Then the dentist office helps fight "for" me against the insurance company by re-submitting it to get repeatedly rejected. It's not much money but I have come to hate them both.

This makes me realize I never got a bill for my oral surgery in December. I got a letter telling me my insurance company was refusing to pay, so presumably I'm supposed to pay out of pocket. But the surgeon never sent me a bill, as far as I know. I wonder if I should call them and ask so I don't start getting hounded by collection agencies or something.

If I pay that I think I'll have spent something like $800 out of pocket on the whole thing. I'm not sure if I could have avoided that by getting a referral from my primary care physician after my dentist initially gave me a referral.

If you're moving from one state to another but haven't moved yet, and need a short-term plan, can you buy it for the state you're moving to? Or do you have to buy it in the state you're still residing in?

46: Other people would know better, but you're asked if you're moving soon and if so they recommend buying for the new state. There might even be more info than that on the site, but I was just playing.

44: I *routinely* get "this is not a bill" notifications from the insurance company saying that I am going to owe some amount of money to the doctor or x-ray tech or whatever, but never get a bill. One wonders if the medical person is just happy with whatever the payout was and not seeking more.

44: I wonder if I should call them and ask so I don't start getting hounded by collection agencies or something.

No, don't do that. Every once in a while I fail to get a bill from a doctor's office despite having received an Explanation of Benefits form from the insurance company (that's the "this is not a bill" thing Oudemia refers to, which you should totally receive every time): if you don't get a bill, don't ask them to bill you, for heaven's sake. Medical providers write off some amount of money every year -- maybe every quarter? -- and they might just have decided to blow that one off.

There's some missing regulatory structure around networks -- there needs to be some regulation placing the onus on the health care provider to affirmatively and correctly inform the patient whether or not they're in that patient's insurance's network, and if they provide services without having done so, prohibiting them from charging the patient more than the patient would have paid if they were in-network. Or something like that.

As it stands, people have to sign forms agreeing to pay anything that might not be covered; this essentially allows providers to get away with being ignorant.

Drum had a post about a related matter recently, recounting the story of a guy who had a routine checkup, but his doctor's office sent the bloodwork to an out-of-network lab, so the guy was on the hook for $800. [What is it about the $800 figure?] That kind of thing pre-dates the ACA: my plan pre-ACA required that bloodwork be done only by a certain lab, so if my doctor's office sent it elsewhere, the cost wasn't covered. For that matter, if I saw a doctor in a hospital, the bloodwork couldn't be done by, or at, that hospital; I had to take myself to the independent, covered lab to have the blood drawn as a separate matter. It was dumb, but those were the terms.

I assume I've been lucky: all my doctors have been aware of all this. The doc at the hospital knew that she couldn't send me down to the second floor for blood to be drawn; my primary care physician knows which lab my blood has to be sent to. It's a ridiculous exercise, and puts a burden on participants, but medical provider offices that profess to be unable to grapple with it aren't doing an essential part of their jobs.

19: In MA Partners Healthcare hospitals and doctors charge a shitload more than anybody else. BleCross is offering plans which don't include them at all (there's probably an exception for transplant surgery), because their rates have been a major driver of healthcare inflation in the Commonwealth. I believe that a couple of plans were able to negotiate deep discounts with Steward Healthcare (a for-profit formerly Catholic system) for limited network plans. Steward agreed so that they would get more volume.

22 and 23: Most commonly psychiatrists who are, of course, MDs but their practices are set up more like psychologists, and a doc who takes no insurance doesn't need a receptionist. This is common in NYC.

medical provider offices that profess to be unable to grapple with it aren't doing an essential part of their jobs.

That grappling doesn't come free. There is a shitload of overhead that comes with maintaining that kind of knowledge in the office. And often that knowledge is gained the hard way - through the process of having patients that get screwed.

It's not free, but it's information that's vital to the patients, and is literally not available to the patients other than through the health care provider. I can't see a better way to make that communication happen other than to make the health care provider financially responsible when it doesn't happen.

One thing that would be quite helpful these days (which is to say, no single payer for at least ten years) is an all-payer claims database. De-vault prices data and let people see what's actually happening. It also has some support from neoliberal types for their fever dreams of a perfect-information health care "market" not needing regulation, so it has some traction.

Lists available online are, IME, not reliably accurate -- there could be some regulatory teeth put into making them accurate, but they're not now. And the other thing I meant by "literally only available from the health care provider" is to address the problem where it's often hard to figure out exactly who is providing you services -- you interact directly with a particular doctor whose relationship with your insurance company you understand, but if you get any kind of complicated testing or treatment done, it's very easy to have services provided by some entity you've never been in direct contact with, at which point unless you're very aware and aggressive about managing things, you can end up unexpectedly out of network.

I'd like the norm to be that anyone providing you services is responsible for alerting you in writing of their relationship to your insurance, and if they don't, the services are provided at their own risk.

Ah, gotcha. The farming out of services can be super annoying even when it is covered. I had a bunch of tests sent out to Quest Diagnostics right around the time there was a mix-up in getting my health insurance renewed, and so Quest's first claims to my insurance were denied. They were very aggressive in sending me bills demanding immediate payment and threatening referral to a collections agency.

Which state? This would be entirely impossible in NY, because the ACA plans have the same network as the oligopoly of insurance providers -- the doctor's office would have to reject all of Blue Cross Blue Shield, which won't happen.

This doesn't necessarily need to be any kind of republican asshattery, as you put it. There's a very simple explanation:

(1) The HIE's really are a different kind of health plan and the insurance company builds separate provider networks for each of its plans,

(2) HIE's have stronger bargaining positions relative to the providers so providers have an incentive to try and band together to drive a better bargain with the insurance companies... that means not participating in networks for HIE's since those plans compensate them at a lower rate

(3) Providers that try this strategy will really hurt their bottom lines in the long run.

That's not to deny that there could be legal issues or this could be some kind of tea party stand, I don't know. Just saying that this COULD be just about money, pure and simple.

The sign is pure GOP assholery, without question. It's possible they only take employer policies, but that seems highly unlikely. It's much more probable that they do take some, but not all individual plans, including ones sold on the exchanges. The red flag to me is calling out exchange plans and Obamacare, two things that aren't relevant to knowing which networks they are part of.

There are ways of posting a "please check with us regarding your insurance network" message without throwing a hissy fit over Obamacare. I wouldn't return to a doctor's office if I saw a sign like this.